Intervention for Disruptive Children Shows Long-Term Benefits

An intervention that teaches children to think before they act out can help them avoid substance abuse in adolescence. In a recent clinical trial, the Utrecht Coping Power Program (UCPP) offset the added vulnerability to cigarettes and marijuana that typically attaches to children's aggressive and disruptive behavioral disorders. Five years after completing the program, 30 teens whose problem behaviors at ages 8 to 13 had been severe enough to warrant professional attention reported no more experience with those substances than a group of peers who had not shown such problems.

The UCPP is a version of the Coping Power Program (CPP), which has improved children's school adjustment in two sizeable trials in the United States. The new study, conducted in the Netherlands, shows that the model can succeed in a European cultural context as well.

From CPP to UCPP

Dr. John Lochman of the University of Alabama and Dr. Karen Wells of Duke University developed CPP in 1994 to help children whose behaviors cause problems in school and family and predict later delinquency and substance abuse. The program trains children to relax, rethink, and generate nonaggressive solutions to situations and social cues that they interpret—often mistakenly—as hostile or threatening.

Clinicians administering CPP use the motto "stop and think" together with a variety of techniques and exercises to enable children to:

revise negative interpretations of others' actions;

manage anger using such techniques as relaxation, distraction, and self-chosen slogans (e.g., "I'll keep my cool and not be a fool.");

shift expectations that aggression will solve problems;

develop nonaggressive ways to handle distressing situations; and

think about short- and long-term consequences.

Children Gain Coping Power: Children use puppets to try out nonaggressive ways to solve a conflict during a session of the Coping Power Program.

During 34 group sessions, children practice these skills extensively in role-playing exercises based on their interactions with peers, teachers, siblings, and parents. In 16 separate group sessions, parents learn to control anger, manage stress, reward their children's good behaviors with attention and small treats, and respond more effectively to misbehavior. Parents and counselors often discuss the lessons conveyed to the children and sometimes watch video from those sessions.

For the Dutch study, Dr. Lochman collaborated with Dr. Walter Matthys of the Rudolf Magnus Institute of Neuroscience in Utrecht to adapt and refine the program. UCPP is more compact than the original version, consisting of 23 child and 15 adult sessions, and UCPP sessions take place in an outpatient mental health clinic rather than a school. Another difference is UCPP's greater emphasis on learning through activities such as role playing and games, which are considered especially appropriate for children with mental health problems. UCPP parents receive briefings on their children's session so that they can reinforce the lessons at home.

Utrecht Coping Power Program Demonstrates Long-Term Benefits: Five years after participating in the Utrecht Coping Power Program (UCPP), adolescents with histories of childhood aggressive disorders reported cigarette and marijuana use rates similar to those of adolescents without such histories and scored no higher on a formal delinquency assessment.

Problem/Treatment

Cigarette Smoking (past month)

Marijuana Use (lifetime)

Delinquency Scale*

Aggression disorder/Standard treatment

42 percent

35 percent

1.5

Aggression disorder/UCPP treatment

17 percent

13 percent

1.2

No aggression disorder/No treatment

20 percent

13 percent

1.2

* Calculated from the National Youth Survey questionnaire and based on 43 delinquency acts, ranging from minor to major offenses.

In a particularly engaging component of both CPP and UCPP, children create a videotape describing frustrating and provocative situations and several solutions to these problems—for example, being verbally assertive rather than physically aggressive—and play them out with others in the group. "Children enjoy making the videos and enthusiastically show them to parents, peers, and teachers," says Dr. Lochman. "The videos give them a chance to show off their new skills and see how the different solutions work out."

Expanding the Program's Reach

In a U.S. study, Dr. Lochman's team has explored how counselor training influences CPP. Examining 57 elementary schools, the researchers found that the program can succeed—and be valued by school staff, parents, and children—in a wide range of settings, but it requires intensive counselor training.

The team next plans to implement CPP in disadvantaged, rural areas of south Alabama. Four international groups, in Puerto Rico, Spain, Ireland, and Italy, are already providing the intervention to small groups of children. Dr. Lochman and colleagues are currently training school counselors from around the world to provide CPP in their home countries.

To further extend use of the program, the investigators have teamed with colleagues at The Johns Hopkins University to generate CPP tailored for middle-school children who live in Baltimore's inner city. The researchers and colleagues at the University of Illinois at Chicago are also developing a CPP program for first-graders that has a more extensive family component.

Benefits Sooner and Later

Dr. Matthys and colleagues recruited 77 children, mostly boys, from psychiatric outpatient clinics and mental health centers. Clinic staff psychiatrists diagnosed the children as having various conditions, including oppositional defiant disorder, conduct disorder, and attention deficit hyperactivity disorder. Each child was randomly assigned to attend either UCPP or a conventional therapy, such as family, behavioral, or other group therapy, for 9 months.

Five years later, 61 trial participants (now aged 14, on average) filled out followup surveys. Their responses indicated that UCPP, but not the conventional therapies, eliminated the extra increment of substance involvement that is normally anticipated among children with histories of disruptive disorders.

Of the 30 respondents who had completed UCPP, 13 percent acknowledged having abused marijuana at least once in their lifetime and 17 percent reported smoking cigarettes in the past month. These rates almost exactly matched those reported by a comparison group of 61 mentally healthy teens of approximately the same age and educational attainment. In contrast, the prevalence of marijuana abuse and smoking were 35 percent and 42 percent, respectively, among 31 teens who had received behavioral or family therapy in the trial.

All of the therapies—UCPP as well as conventional—reduced disruptive behaviors and delinquency equally well. As assessed by the parents immediately after the close of the trial, UCPP had a much greater effect on the children's problem behaviors than behavioral treatment and marginally more than family therapy. At the 5-year followup, the teens who had either received UCPP or one of the other therapies reported rates of antisocial activities—including stealing, destroying property, fighting, and cheating on tests—similar to those of their healthy peers.

"Children who show aggression are an important and difficult group to work with, and it is impressive that UCPP produced lasting benefits," says Dr. Eve Reider of NIDA's Division of Epidemiology, Services and Prevention Research. "The children and their parents appeared to learn skills in the program that helped the children resist drug use and avoid other trouble 5 years later." She notes that these results are consistent with other NIDA-funded research showing long-term effects of prevention interventions for youth who are at risk for drug use and other problem behaviors.

NIDA's International Program supported the UCPP evaluation under an ongoing collaboration between NIDA researchers and the Dutch Addiction Program. "This study is a good example of collaborations between NIDA-funded investigators in the United States and international researchers that focus on adapting and testing interventions in other cultures," says Dr. Steven Gust, director of NIDA's International Program.

Manuals for CCP are available for purchase from Oxford University Press, www.oup.com.

Zonnevylle-Bender, M.J.S., et al. Preventive effects of treatment of disruptive behavior disorder in middle childhood on substance use and delinquent behavior. Journal of the American Academy of Child and Adolescent Psychiatry 46(1):33-39, 2007. [Abstract]

Van de Wiel, N.M., et al. The effectiveness of an experimental treatment when compared to care as usual depends on the type of care as usual. Behavior Modification 31(3):298-312, 2007. [Abstract]

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National Institute on Drug Abuse. Intervention for Disruptive Children Shows Long-Term Benefits Retrieved from http://www.drugabuse.gov/news-events/nida-notes/2009/10/intervention-disruptive-children-shows-long-term-benefits